[ARTICLE] The effect of gamified robot-enhanced training on motor performance in chronic stroke survivors – Full Text

Abstract

Task-specific training constitutes a core element for evidence-based rehabilitation strategies targeted at improving upper extremity activity after stroke. Its combination with additional treatment strategies and neurotechnology-based solutions could further improve patients’ outcomes. Here, we studied the effect of gamified robot-assisted upper limb motor training on motor performance, skill learning, and transfer with respect to a non-gamified control condition with a group of chronic stroke survivors. The results suggest that a gamified training strategy results in more controlled motor performance during the training phase, which is characterized by a higher accuracy (lower deviance), higher smoothness (lower jerk), but slower speed. The responder analyses indicated that mildly impaired patients benefited most from the gamification approach. In conclusion, gamified robot-assisted motor training, which is personalized to the individual capabilities of a patient, constitutes a promising investigational strategy for further improving motor performance after a stroke.

1. Introduction

Stroke is a major contributor to the global burden of disease [1]. It has been estimated that the absolute number of stroke survivors remaining disabled after an ischemic stroke has increased 1.4- to 1.8-folds between 1990 and 2013 [1]. Particularly, many stroke survivors are affected by upper limb motor impairment, in which magnitude largely determines the successful reintegration into an independent personal and professional life [2, 3]. This current state urgently requires further development of efficient treatments for post-stroke motor rehabilitation.

Currently, task-specific training constitutes a core element of evidence-based upper extremity rehabilitation programs [4]. Task-specific training relies on the finding that repetitive and consistent practice of meaningful and challenging tasks optimally engage intrinsic neuronal plasticity and can result in meaningful functional improvements [5]. Task-specific training can be incorporated or combined with other emerging behavioral interventions such as constraint-induced movement therapy, mirror therapy, motor imagery/mental practice [6] and neurotechnology-based solutions such as robot-assisted training [4, 7, 8]. Recently, a set of research strategies has been proposed aiming to further facilitate the design of efficient novel rehabilitation approaches and their clinical implementation [3]. Some of them are: (i) the combined application, (ii) personalization, and (iii) intensified training.

In our present work, we investigated the combined application of a gamified training strategy and robot-assisted upper extremity training. Gamification is defined as the use of game design elements in traditionally non-game contexts [9]. Common game design elements are, for instance, specific tasks (e.g., collect a target), rules (e.g., do not crash into the walls of a maze), or point systems (e.g., number of collected targets) [10]. Researchers have proposed that when designing gamified applications for rehabilitation, two game design principles are of particular importance – meaningful play and challenge [11]. Meaningful play corresponds to the presence of an apparent relationship between own actions and the system outcome for the user [12]. Challenge refers to the optimal adaptation of the task demands to the user’s ability accounting for the trade-off of being potentially too easy and thereby risking loss of interest and boredom or of being too difficult, which may lead to frustration and termination of the activity [11]. Both design principles were incorporated into our tested intervention. The motor training was implemented using the Cellulo robotic platform [14, 15]. The platform consists of palm-sized, graspable, haptic-enabled tangible robots, printed paper sheets on which the robots are operating and a tablet/phone or computer controlling the application [13]. These “computer-mouse-like” robots allow users to interact with printed visual elements on paper, such as walls in a maze, and can provide visual and haptic feedback. Our main aim by using the Cellulo platform was to provide an intuitive, easy-to-use and easy-to-set-up system for motor training that allows for tangible interaction with the game elements.

Previous research has tested the use of gamification strategies for rehabilitation applications, for review see, e.g., Ferreira and colleagues [10]. However, knowledge on the induced behavioral pattern and possible underlying mechanisms in clinical populations is largely lacking. In this proof-of-principle study, we strove to address this by systematically testing potential effects of a gamified robot-based upper extremity motor training in a controlled study. We hypothesized that a gamified application strategy leads to enhanced control of the robotic device during the training sessions when compared to a non-gamified control condition resulting in enhanced motor performance. Please see Figure 1 for an illustration of an exemplary scenes while a patient trains with both modalities. The respective experimental work and analyses were guided by the following research questions:•

RQ1: Does a gamified application lead to enhanced motor performance during the training phase compared to a non-gamified application?•

RQ2: Does a gamified training application lead to enhanced motor skill learning compared to a non-gamified application?•

RQ3: Does the training strategy – gamified versus non-gamified – have an impact on skill transfer to simple robot manipulation?•

RQ4: Is the magnitude of the gamification effect associated with patient characteristics determined by clinical motor scales and assessments?•

RQ5: Which training strategy do patients prefer based on their self-assessment?

In the following sections, we characterize the induced behavioral pattern and provide insights into potential underlying mechanisms of gamified robot-assisted motor training paradigms allowing one to further test the potential of haptic-enabled robot-enhanced gamified training in future randomized clinical trials. […]

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[Abstract] Virtual reality in physical rehabilitation: a narrative review and critical reflection

Abstract

Background

Digital technologies are increasingly more ubiquitous with every passing year and have the potential to revolutionize how humans interact. In the realm of physical rehabilitation, the use of virtual reality (VR) is an area that has continued to see growth as a technology that could allow for new avenues of physical therapy practice.

Objectives

This manuscript starts with a narrative review of the emergence of virtual reality technology for use in rehabilitation and the original vision of this relationship as a means to understand its trajectory for the future. We then consider the current benefits and harms of using virtual reality technologies in the physical rehabilitation space.

Major Findings

VR technologies are becoming smaller and cheaper with every given year, with many new applications in physical rehabilitation (e.g. restoration of range of motion or pain control). We appear to be at a point in history where VR may be able to be successfully used on a wider scale in physical rehabilitation. The use of VR in physical rehabilitation has potential, but greater effort is required to elucidate its standardized operating procedures as well to guide the ethics in its use. Clinicians may also need to learn new competencies to implement VR effectively.

Conclusions

Collaboration is required between patients, clinicians, and scientists to help guide the use of VR within physical rehabilitation. This work is intended to act as a resource to clinicians and scientists in the field looking to develop a greater understanding of VR within physical rehabilitation.

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[Abstract] A web-based gamification of upper extremity robotic rehabilitation – Conference Publication

Abstract

In recent years, gamification has become very popular for rehabilitating different cognitive and motor problems. It has been shown that rehabilitation is effective when it starts early enough and it is intensive and repetitive. However, the success of rehabilitation depends also on the motivation and perseverance of patients during treatment. Adding serious games to the rehabilitation procedure will help the patients to overcome the monotonicity of the treatment procedure better. On the other hand, if we can use different serious games with a robotic rehabilitation system, it will help us to define more easily tasks with different levels of difficulty, or again, to set up more options for patients to choose the desired game, among the existing games, for practicing the therapeutic tasks. This article provides a procedure for connecting a rehabilitation robot to several web games. In this vein, we designed an interface and connected our robot to the computer with a serial port. Finally, we proved our method with a survey from an experiment, And we demonstrate that having several games besides rehabilitation makes the procedure of rehabilitation entertaining.

References

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[Book Chapter] Serious Games Design Principles Using Virtual Reality to Gamify Upper Limb Stroke Rehabilitation: The Importance of Engagement for Rehabilitation

Robert Herne (Murdoch University, Australia), Mohd Fairuz Shiratuddin (Murdoch University, Australia), Shri Rai (Murdoch University, Australia) and David Blacker (Perron Institute, Australia)
Source Title: Handbook of Research on Cross-Disciplinary Uses of Gamification in Organizations

OnDemand PDF Download: Available$37.50

Abstract

Stroke is a debilitating condition that impairs one’s ability to live independently while also greatly decreasing one’s quality of life. For these reasons, stroke rehabilitation is important. Engagement is a crucial part of rehabilitation, increasing a stroke survivor’s recovery rate and the positive outcomes of their rehabilitation. For this reason, virtual reality (VR) has been widely used to gamify stroke rehabilitation to support engagement. Given that VR and the serious games that form its basis may not necessarily be engaging in themselves, ensuring that their design is engaging is important. This chapter discusses 39 principles that may be useful for engaging stroke survivors with VR-based rehabilitation post-stroke. This chapter then discusses a subset of the game design principles that are likely to engage stroke survivors with VR designed for upper limb rehabilitation post-stroke.

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Introduction

Stroke affects an individual’s ability to live independently, because it impairs their ability to perform basic activities such as eating, dressing, washing and walking (Ploderer et al., 2017). Given the impact a stroke has on someone’s life and independence, rehabilitation is important. Engagement with the rehabilitation process has been recognised as playing a crucial part in stroke rehabilitation, increasing a stroke survivor’s recovery rate and positive outcomes of their rehabilitation (MacDonald et al., 2013). Gamification is considered to be important with the engagement process. According to Patricio et al. (2020):

Gamification is the process of making activities more game-like in non-game contexts to encourage users’ motivation and engagement in a particular task.

Patrício et al. (2018) also stated that:

Effective gamification approaches attempt to encourage users’ engagement, amusement, and enjoyment toward various activities.

Because of the importance of gamification, this chapter discusses various Serious Games (which form the basis of VR) Design Principles using VR to enable the gamification of stroke rehabilitation for improved engagement. The chapter begins with a background discussion of stroke, rehabilitation, Serious Games, VR and the use of VR for stroke rehabilitation. The chapter then provides a discussion of game design principles that may be applicable in the design of VR for gamified stroke rehabilitation, with the aim of making it more engaging. The chapter concludes by discussing an application of the principles to upper limb rehabilitation post-stroke. This research identified which of the game design principles discussed are likely to engage stroke survivors with VR designed for upper limb rehabilitation post-stroke.

Background

Stroke

The Stroke Foundation of Australia (What is a stroke — Stroke Foundation – Australia, 2021) provides this layperson definition of stroke:

Your brain is fed by blood carrying oxygen and nutrients through blood vessels called arteries. A stroke happens when blood cannot get to your brain because of a blocked or burst artery. As a result, your brain cells die due to a lack of oxygen and nutrients.

Physical impairments potentially caused by a stroke include impaired movement of limbs (Norman, 2014). Having upper limb impairment means that one arm is likely to be paralysed or suffer from limited movement. A paralysed arm curls upwards into a wing with a clenched fist. Having only one good arm makes tasks that require or are much easier to perform with two arms very difficult. This can include simple domestic tasks such as opening a jar or using a telephone.

Stroke Rehabilitation

Intensive rehabilitation after a stroke is crucial to minimise long-term effects, improve rehabilitation results and decrease the responsibility placed on carers and health care systems (Langstaff et al., 2014).

Physical Rehabilitation

Physical rehabilitation includes rehabilitation of both the upper and lower limbs, including motor skills, gait and balance. Conventionally, a course of physiotherapy is used in the physical rehabilitation of stroke survivors. Other methods used for physical rehabilitation include Serious Games (see the section “Stroke Rehabilitation and Serious Games” for an in-depth discussion of this) and VR (see the section “Stroke Rehabilitation and Virtual Reality”).

Rehabilitation and Engagement

Engagement with the rehabilitation process has been recognised as playing a crucial part in stroke rehabilitation, increasing a stroke survivor’s rate of rehabilitation and rehabilitation outcomes (MacDonald et al., 2013). If they are not engaged, they may fail to attempt rehabilitation and lose what movement they have remaining. Therefore, stroke survivor engagement with their rehabilitation is critical. To engage is defined as (Oxford Dictionary of English, 2010): “occupy or attract (someone’s interest or attention).”

Key Terms in this Chapter

Non-Serious Game: A game designed purely for entertainment.

Engagement: Having one’s attention or interest attracted or occupied ( Oxford Dictionary of English , 2010 AU70: The in-text citation "Oxford Dictionary of English, 2010" is not in the reference list. Please correct the citation, add the reference to the list, or delete the citation. ).

Virtual Reality (VR): “A computer-based, interactive, multisensory simulation environment that occurs in real-time. VR presents users with opportunities to engage in activities within environments that appear, to various extents, similar to real-world objects and events” ( Henderson et al., 2007 ).

Serious Game: Games with greater aims than entertainment, intended for learning and behavioural alteration ( Connolly et al., 2014 ).

Stroke: “The clinical syndrome of rapid onset of focal (or global, as in subarachnoid haemorrhage) cerebral deficit, lasting more than 24 hours or leading to death, with no apparent cause other than a vascular one” ( Warlow et al., 2003 ).

Game Design Principle: A single concept that can inform a segment or the entirety of the specifications of a game.

Rehabilitation: “The action of restoring someone to health or normal life through training and therapy after imprisonment, addiction, or illness” ( Oxford Dictionary of English , 2010 AU71: The in-text citation "Oxford Dictionary of English, 2010" is not in the reference list. Please correct the citation, add the reference to the list, or delete the citation. ).[…]

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[Abstract] Design of a hand rehabilitation gaming platform using IoT technologies – IEEE Conference Publication

Abstract

Nowadays, elements of the game can be met more often in regular processes. Education, business, marketing and many other spheres are being included with gaming elements, since games, according to conducted studies, positively affect people and make them happier. Also, games reduce stress and help to be focused on specific tasks. Today’s technologies such as virtual reality tools provide huge opportunities for developers to create projects that can be used as a key element that improves the efficiency and results of certain processes.This article presents a gaming platform for hand rehabilitation, which includes the use of a Leap Motion controller in conjunction with an Arduino-based robotic arm. The main idea of gamification of hand rehabilitation is to help improve the accuracy of gestures, coordination, and also restore the functionality of the hands using the capabilities of Leap Motion and Arduino.

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[Abstract] PhyRe Up! A system based on mixed reality and gamification to provide home rehabilitation for stroke patients

Abstract

Stroke represents a global concern that currently affects a significant part of the world’s population. Physical rehabilitation plays a fundamental role for stroke patients to recover mobility and improve quality of life. This process is costly, considering that patients must attend face-to-face rehabilitation sessions in hospitals or rehabilitation centers. Plus, there is a lack of specialized medical staff, who are usually insufficient to properly address the growing number of stroke patients that need physical rehabilitation. This situation has been exacerbated by the COVID-19 pandemic, as some of the human resources have been devoted to fight against the pandemic, and the physical presence of rehabilitation patients in hospitals has been severely limited. This paper proposes PhyRe Up!, a novel remote rehabilitation system that uses mixed reality and gamification techniques. PhyRe Up! has been devised for stroke patients to perform therapeutic exercises at home, with great precision, and with the potential supervision of clinicians. The system aims to increase the patient’s motivation as well as maintaining the quality of performance for the exercises, similar to the obtained levels when attending face-to-face sessions with therapists. The underlying architecture combines declarative, procedural, and conditional knowledge to manage the rehabilitation process, which offers flexibility and scalability to enhance the capabilities of the proposed system. Experimental results highlight how the combination of mixed reality and gamification significantly influences the accuracy of rehabilitation exercises previously defined by therapists. Particularly, the conducted experiments in the first validation phase of PhyRe Up! shows that our proposal drastically reduces the intermediate steps required to complete an exercise thanks to the provided visual feedback. The accuracy with which the patient performs the assessed exercise for the first time is greater than when using traditional rehabilitation techniques.

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[Abstract] Application of Gamification Tool in Hand Rehabilitation Process

Abstract

Video games are constantly evolving and today they are one of the main types of entertainment. As we live in the digital age, the implementation of IT solutions in other areas of activity remains relevant. Today, almost all processes use IT technologies: calling a taxi, ordering food, education, shopping, and so on. The use of IT technologies in the field of medicine is not uncommon. But it’s not often that you see video games being used in this area. Video games and their development are an integral part of the IT sphere. The technologies that exist now allow us to create our own game products, which can then be implemented in other processes. This research is aimed at studying the term of “gamification”, its impact on rehabilitation processes, and the study of gamification tools and game products used in the field of medicine. In this research we propose a gamified solution for hand rehabilitation process which include 3D game that work in conjunction with the VR tool called Leap Motion. Since video games attract people with reward systems, goals and many other factors, why not to use it as a key element in process of rehabilitation? In some cases, it is more effective method rather than traditional therapy.

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[ARTICLE] Serious games for upper limb rehabilitation after stroke: a meta-analysis – Full Text

Abstract

Background

Approximately two thirds of stroke survivors maintain upper limb (UL) impairments and few among them attain complete UL recovery 6 months after stroke. Technological progress and gamification of interventions aim for better outcomes and constitute opportunities in self- and tele-rehabilitation.

Objectives

Our objective was to assess the efficacy of serious games, implemented on diverse technological systems, targeting UL recovery after stroke. In addition, we investigated whether adherence to neurorehabilitation principles influenced efficacy of games specifically designed for rehabilitation, regardless of the device used.

Method

This systematic review was conducted according to PRISMA guidelines (PROSPERO registration number: 156589). Two independent reviewers searched PubMed, EMBASE, SCOPUS and Cochrane Central Register of Controlled Trials for eligible randomized controlled trials (PEDro score ≥ 5). Meta-analysis, using a random effects model, was performed to compare effects of interventions using serious games, to conventional treatment, for UL rehabilitation in adult stroke patients. In addition, we conducted subgroup analysis, according to adherence of included studies to a consolidated set of 11 neurorehabilitation principles.

Results

Meta-analysis of 42 trials, including 1760 participants, showed better improvements in favor of interventions using serious games when compared to conventional therapies, regarding UL function (SMD = 0.47; 95% CI = 0.24 to 0.70; P < 0.0001), activity (SMD = 0.25; 95% CI = 0.05 to 0.46; P = 0.02) and participation (SMD = 0.66; 95% CI = 0.29 to 1.03; P = 0.0005). Additionally, long term effect retention was observed for UL function (SMD = 0.42; 95% CI = 0.05 to 0.79; P = 0.03). Interventions using serious games that complied with at least 8 neurorehabilitation principles showed better overall effects. Although heterogeneity levels remained moderate, results were little affected by changes in methods or outliers indicating robustness.

Conclusion

This meta-analysis showed that rehabilitation through serious games, targeting UL recovery after stroke, leads to better improvements, compared to conventional treatment, in three ICF-WHO components. Irrespective of the technological device used, higher adherence to a consolidated set of neurorehabilitation principles enhances efficacy of serious games. Future development of stroke-specific rehabilitation interventions should further take into consideration the consolidated set of neurorehabilitation principles.

Background

Each year more than 1 million Europeans suffer from stroke and approximately two-thirds of survivors maintain upper limb (UL) paresis [1]. This number is expected to rise by 35% in upcoming years [2] leading to additional rehabilitation needs. To this date, few people attain complete UL recovery 6 months after stroke [3]. New interventions targeting the UL aim for better outcomes in activities of daily living (ADL), functional independence and quality of life. Alongside conventional therapies, recent developments offer possibilities in self- and tele-rehabilitation [4] which could help manage, cost-efficiently [5], increasing rehabilitation demands.

Technological improvements in robot assisted therapy (RAT) and virtual reality (VR) systems (VRS) enhance patient care and facilitate therapist assistance during UL rehabilitation [6, 7]. First, RAT promotes the use of the affected limb, intensifies rehabilitation through task repetition and offers task-specific practice [7]. Effectiveness of RAT is established for UL rehabilitation after stroke [8, 9]. Secondly, VRS provide augmented feedback, preserve motivation and are becoming cost-efficient [5]. Recent meta-analyses suggest a superior effect of VR-based interventions compared to conventional treatment on UL function and activity after stroke, especially if developed for this specific purpose [10–12]. Authors attributed these findings to the fact that VRS specifically developed for rehabilitation, as opposed to commercial video-games (CVG), fulfil numerous neurorehabilitation principles.

Typically, a common denominator of VRS and RAT is playful interventions by means of serious games [13, 14]. A serious game is defined as a game that has education or rehabilitation as primary goal. These games combine entertainment, attentional engagement and problem solving to challenge function and performance [15, 16]. Moreover, they comply with several motor relearning principles that constitute the basis of effective interventions in neurorehabilitation [11, 16]. For example, some devices adapt game difficulty to stimulate recovery and maintain motivation [15]. Others incorporate functional tasks mimicking ADL in virtual environments and provide performance feedback during and/or after task completion [17]. Characteristics of serious games differ depending on targeted rehabilitation purposes and technical specificities of the system they are implemented on.

Previous work on the efficacy of VR-based interventions indicated that serious games may enhance UL recovery after stroke [11, 12, 18]. However, why such interventions, specifically developed for rehabilitation purposes and implemented on various types of devices (such as robots, smartphones, tablets, motion capture systems, etc.), may constitute effective therapies for UL rehabilitation after stroke needs to be further investigated. Recent theoretical research proposed consolidation of commonly acknowledged neurorehabilitation principles [16]. Usually, serious games comply with several of these principles which creates an opportunity to evaluate clinical applicability of the consolidated set of principles. To this day, it remains unclear whether higher adherence to this consolidated set of neurorehabilitation principles enhances efficacy of interventions. In addition, it is not well known whether adherence to specific principles influences efficacy. Finally, rehabilitation effects on participation outcomes remain relatively unexplored. In this context, efficacy of interventions should be addressed in terms of all components of the World Health Organization’s International Classification of Function, Disability, and Health (ICF-WHO) model [19].

The main objective of this systematic review and meta-analysis was to address the following question in PICOS form: in adults after stroke (P), do serious games, implemented on various technological systems (I), show better efficacy than conventional treatment (C), to rehabilitate UL function and activity, and patient’s participation (O)? A secondary objective was to assess whether higher adherence to a consolidated set of neurorehabilitation principles enhances efficacy of games specifically designed for rehabilitation, irrespective of the technological device used.[…]

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[Book Chapter] Gamification as Upper Limb Rehabilitation Process

Abstract

In our modern life world, health and well-being strongly depend on the individual’s health behaviours. Motivation is a major factor of health behaviour change, and intrinsically motivated behaviour change is desirable as it is both sustained and directly contributes to well-being. This raises the immediate question what kind of interventions are best positioned to intrinsically motivate health behaviour change. The current state of evidence supports that gamification can have a positive impact in health and wellbeing. In recent years, games and game technology have been used quite widely to investigate if they can help make rehabilitation more engaging for users. The underlying hypothesis is that the motivating qualities of games may be harnessed and embedded into a game-based rehabilitation system to improve the quality of user participation

Complete Chapter List

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Table of Contents View Full PDF

Detailed Table of Contents View Full PDF

Preface, Ricardo Alexandre Peixoto de Queirós, António José Marques View Full PDF

Acknowledgment, Ricardo Alexandre Peixoto de Queirós, António José Marques View Full PDF

Chapter 1 Ethical Issues of Gamification in Healthcare: The Need to be Involved (pages 1-19)Luis Coelho, Sara Reis Sample PDF $37.50

Chapter 2 Why Gamification Is Not the Solution for Everything (pages 20-33)Tiago Pereira da Silva Sample PDF $37.50

Chapter 3 Structural Modeling and Analysis of Barriers Encountered in Gamification Applications in Health (pages 34-53)Gözde Koca, Özüm Eğilmez Sample PDF $37.50

Chapter 4 Learning Systems and Gamification: Blending Augmented and Virtual Reality With Gamification Strategies (pages 54-67)Barbara Cleto Sample PDF $37.50

Chapter 5 Software Requirements Definition Processes in Gamification Development for Immersive Environments (pages 68-78)Paulo Veloso Gomes, João Donga, Vítor J. Sá Sample PDF $37.50

Chapter 6 The Role of Gamification in Neurocognitive Rehabilitation (pages 80-99)Artemisa Rocha Dores, Andreia Geraldo, Helena Martins Sample PDF $37.50

Chapter 7 Biomedical Analysis of Social Media/Video Games Addiction and Gamification of Neurocognitive Therapy for Rehabilitation (pages 100-111)Venugopal D., Kalirajan K., Seethalakshmi V. Sample PDF $37.50

Chapter 8 Gamification in Dementia and Mild Cognitive Impairment (pages 112-131)Vitor Simões-Silva, Susana Alexandra Mendonça Gregório, Tarcisio de Tarco Moura Luz, Ana Francisca Casinhas Coutinho Lapa, António Marques Sample PDF $37.50

Chapter 9 The Use of Gamification in Social Phobia (pages 132-153)Vitor Simões-Silva, Vanessa Maravalhas, Ana Rafaela Cunha, Maria Inês Soares, António Marques Sample PDF $37.50

Chapter 10 Positive Play: Games for Human Potential and the Yet Unexplored Case of Anorexia Nervosa (pages 154-185)Pedro Cardoso, Viviane Peçaibes, Bruno Giesteira, Liliana Correia de Castro Sample PDF $37.50

Chapter 11 mHealth for Illness Self-Management for People With Schizophrenia: Opportunities and Implications in Gamification (pages 186-204)Raquel Simões de Almeida Sample PDF $37.50

Chapter 12 Carnival Play: eHealth Solution to Evaluate, Rehabilitate, and Monitor Dexterity and Manual Strength (pages 206-242)Bruno Giesteira, Joana Silva, Teresa Sarmento, Paulo Abreu, Maria Teresa Restivo Sample PDF $37.50

Chapter 13 Gamification as Upper Limb Rehabilitation Process (pages 243-257)Vitor Simões-Silva, Ana Filipa Duarte Mesquita, Karla Lígia Santos Da Silva, Vanessa Solange Arouca Quental, António Marques Sample PDF $37.50

Chapter 14 Fun and Games: How to Actually Create a Gamified Approach to Health Education and Promotion (pages 258-278)Helena Martins, Artemisa Dores Sample PDF $37.50

Chapter 15 Nutrify: Promoting Nutrition Literacy Using Gamification (pages 279-292)C. Balakrishna, Thota Ganesh, Arun Khosla Sample PDF $37.50

Chapter 16 Gamification: Improving Patient Adherence in mHealth for Diabetes Management (pages 293-319)Diogo Machado, Rui Carvalho, Pedro Brandão Sample PDF $37.50

About the Contributors View Full PDF

Index View Full PDF

Source Title: Handbook of Research on Solving Modern Healthcare Challenges With Gamification

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[Scoping Review] Serious Gaming Technology in Upper Extremity Rehabilitation – Full Text

ABSTRACT

Background: Serious gaming has increasingly gained attention as a potential new component in clinical practice. Specifically, its use in the rehabilitation of motor dysfunctions has been intensively researched during the past three decades.

Objective: The aim of this scoping review was to evaluate the current role of serious games in upper extremity rehabilitation, and to identify common methods and practice as well as technology patterns. This objective was approached via the exploration of published research efforts over time.

Methods: The literature search, using the PubMed and Scopus databases, included articles published from 1999 to 2019. The eligibility criteria were (i) any form of game-based arm rehabilitation; (ii) published in a peer-reviewed journal or conference; (iii) introduce a game in an electronic format; (iv) published in English; and (v) not a review, meta-analysis, or conference abstract. The search strategy identified 169 relevant articles.

Results: The results indicated an increasing research trend in the domain of serious gaming deployment in upper extremity rehabilitation. Furthermore, differences regarding the number of publications and the game approach were noted between studies that used commercial devices in their rehabilitation systems and those that proposed a custom-made robotic arm, glove, or other devices for the connection and interaction with the game platform. A particularly relevant observation concerns the evaluation of the introduced systems. Although one-third of the studies evaluated their implementations with patients, in most cases, there is the need for a larger number of participants and better testing of the rehabilitation scheme efficiency over time. Most of the studies that included some form of assessment for the introduced rehabilitation game mentioned user experience as one of the factors considered for evaluation of the system. Besides user experience assessment, the most common evaluation method involving patients was the use of standard medical tests. Finally, a few studies attempted to extract game features to introduce quantitative measurements for the evaluation of patient improvement.

Conclusions: This paper presents an overview of a significant research topic and highlights the current state of the field. Despite extensive attempts for the development of gamified rehabilitation systems, there is no definite answer as to whether a serious game is a favorable means for upper extremity functionality improvement; however, this certainly constitutes a supplementary means for motivation. The development of a unified performance quantification framework and more extensive experiments could generate richer evidence and contribute toward this direction.

Introduction

Serious Gaming in Upper Limb Motor Rehabilitation

Motor rehabilitation in various parts of the body such as the upper or lower limbs aims to help patients restore dysfunctions that affect their mobility. In this scoping review, we focus on motor disabilities related to the upper extremities. The motivation behind this review was first introduced within one of our group’s research projects related to upper limb rehabilitation, termed “Modern Interface Platform for Motor Control and Learning on People With Motor Disorders” [1–3]. Our purpose was to search the literature regarding upper limb rehabilitation using serious games to provide guidance for proceeding with creation of the project’s platform. With the term “serious games,” we refer to video games created with a purpose other than entertainment, such as education, health care, politics, and engineering. The aim of this study was to review all of the upper limb rehabilitation techniques related to serious games regardless of the cause of motor dysfunctions.

Therapists have developed several clinical methods to indicate motor ability, such as range of motion (ROM) or range of force. In addition, specialized evaluation tests such as Fugl-Meyer Motor Function Assessment (FMA), Action Research Arm Test (ARAT), and Melbourne Assessment of Unilateral Upper Limb Function (MAUULF) aim to estimate the improvement of a patient’s motion condition. The usual rehabilitation scheme consists of repeated motion exercises for a specific body part, with the aim of restoring ability as close to the normal condition as possible.

The idea to introduce gamification to the therapeutic protocol of upper limb rehabilitation was born as a means to motivate patients during the rehabilitation schemes but also represents a new method for monitoring the upper limb motion for further analysis. The first attempts of the introduction of gamification in upper limb rehabilitation appeared in 1999 by a team at Rutgers University [4], making use of a custom prototype robotic arm aiming to map the motion of the palm and wrist with force resistance. This concept was extended with development of a computer-based game that guides the patient to make various movements with the palm and fingers. The same system went through various modifications [5–7], and the latest version of the system was published a few years later [8–11], including significant alterations and improvements regarding the digital environment and the therapeutic approach. Among these early attempts, a study published in 2000 [12] presented a system that uses a robotic device in conjunction with the commercial game Arkanoid for wrist rehabilitation, and another study published in 2002 [13] described an equivalent approach using a resistive joystick.

These rapid technological developments led to more elaborate devices regarding motion capture, challenging researchers in this field to investigate this type of rehabilitation.

Significance of This Scoping Review

Over the last few decades, there has been an increasing amount of studies regarding the enhancement of rehabilitation with the introduction of new technologies. A systematic review on the implementation of serious games and wearable technology in rehabilitation practices for patients recovering from traumatic bone and soft tissue injuries was published by Meijer et al [14]. Another review attempted to depict the implementations of brain-computer interfaces in the rehabilitation of motor dysfunctions following stroke [15]. Nonetheless, these overviews do not include games specifically developed for rehabilitation or “wearable-controlled” games. Therefore, the primary aim of this scoping review was to summarize the field of upper extremity rehabilitation combined with serious games, providing a map of the research approaches used to date. The main research goals were to: (1) explore the technologies used for upper limb rehabilitation; (2) discover distinct methods, common characteristics, and objectives of these efforts; (3) identify challenges and limitations from these previous efforts; and (4) examine the types of analysis methods used to quantify the treatment outcome.

This effort will contribute to the detection of gaps or limitations in this area, and may lead to new research paths and ideas.

The rest of the paper is organized as follows. The Methods section depicts the procedure that was followed regarding the literature search, data management, and eligibility criteria of this review. The Results section presents the statistical results, including figures, after reviewing the included studies. Finally, the Discussion section comments on the results and delineates possible limitations of this study, along with highlighting the importance of this review for further development of this research area.[…]

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Figure 4. Overview of the devices used in the included studies. The green nodes indicate the sensors included in the commercial sensor category, while the orange nodes are those included in the hardware development category. The dark green nodes represent sensors that have been used individually or in combination with one of the sensors represented by the light green nodes.